Sexually Transmitted Infections

Global burden of sexually transmitted infections
The World Health Organization estimates that each year more than 340 million new cases occur of bacterial and protozoal sexually transmitted infections (STIs). These infections are a central cause of acute disease, infertility, and perinatal morbidity and mortality. [1] Untreated cases of maternal gonorrhea and chlamydia infections also lead to an estimated 4,000 cases of neonatal blindness worldwide. [1]

Pre-arrival in the U.S.
All refugees undergo a mandatory medical examination while they are overseas prior to their resettlement in the U.S.  This medical examination focuses on certain inadmissible conditions. Inadmissible conditions include infectious diseases such as tuberculosis, Hansen disease, and sexually transmitted diseases; mental disorders associated with harmful behavior; and substance abuse or addiction.  Several STIs are considered “inadmissible” and require either treatment and/or a special waiver before refugees are allowed to resettle in the U.S.

U.S. providers are familiar with the most common STIs encountered in refugees, which include syphilis, gonorrhea, chlamydia, trichomonas, genital warts, and bacterial vaginosis.  Prior to resettlement, laboratory testing is performed in conjunction with the overseas medical examination for persons who are 15 years or older to confirm the diagnosis of syphilis (VDRL or RPR).   Refugees may have other infections such as chancroid, granuloma inquinale, and lymphogranuloma venereum that would be familiar to U.S. clinicians as well.

Post-arrival in the U.S.
There is little data available to guide recommendations for the screening of refugees after arrival in the U.S.  One recent study focused on syphilis, gonorrhea and chlamydia retrospectively by reviewing the medical records of 25,779 refugees from multiple populations who arrived in the U.S. from 2003 to 2010. Of this population, approximately 2,500 refugees were screened for gonorrhea and/or chlamydia. Surprisingly, the overall prevalence rate for these infections was very low.  Among the refugees who were screened, 0.4% were found to have gonorrhea and just 0.6% were found to have chlamydia. [2] Of the more than 17,235 refugees tested for syphilis, there was an overall prevalence rate of 1.1%. [2] This finding aligns with other smaller studies and anecdotal experience of many clinicians who reported low prevalence of gonorrhea and chlamydia in refugee populations. [3]

Due to indications that the overall rates of gonorrhea and chlamydia are low in refugee populations and a lack of STI data specific to refugees, the CDC has recommended screening that is consistent with the overall recommendations for the general U.S. population. [4,5]  These guidelines do not recommend routine screening of males for chlamydia unless the population is felt to be at high risk. Current recommendations for routine STI screenings are:


  • Women and girls < 25 years old who are sexually active or those with risk factors (e.g. multiple or new partners),
  • Leucoesterase (LE) positive on urine sample, or
  • Women or children with a history of or at risk for sexual assault


  • Leucoesterase (LE) positive on urine sample, or
  • Women or children with a history of or at risk for sexual assault


When overseas test results for syphilis are available and negative, repeat testing post-arrival in the U.S. is not necessary unless the refugee is considered high-risk.*  However, screening may be considered for those:

Less than 15 years of age

  • Exposure to countries endemic for other treponemal subspecies that cross-react and may be found in children (e.g. yaws, bejal, pinta)
  • Sexually active or have a history of sexual assault

15 years of age or older

  • Those with unknown overseas test results or who are at high risk of newly acquired infection.*

Screening should be considered for specific populations that are suspected or confirmed to have high rates of STIs.  In addition, all refugees with suspected clinical infection should undergo a thorough evaluation according to their signs and symptoms.

* Note, this differs from currently posted CDC guidelines and are the opinion of the author.

Contributed by William Stauffer M.D., M.S.P.H., University of Minnesota

1. World Health Organization. Global Strategy for the Prevention and Control of Sexually Transmitted Infections 2006-2015: breaking the chain of transmission. WHO 2007. Available at: Accessed Feb 3, 2011.

2. Stauffer WM, Painter J, Mamo B, et al. Sexually transmitted infections in newly arrived refugees: is routine screening for Neisseria gonorrhea and Chlamydia trachomatis infection indicated? Am J Trop Med Hyg 2012;86(2):392-5.

3. Paxton GA, Sangster KJ, Maxwell EL, et al. Post-arrival health screening in Karen refugees in Australia. PLoS One 2012;7(5):e38196:1-7.

4. United States Preventative Services Task Force, 2007. Screening for chlamydial infection: recommendation statement. Ann Intern Med 147:128-34.

5. United States Preventive Services Task Force, 2005. Screening for gonorrhea: recommendation statement. Ann Fam Med 3: 263-7.